Care pathway

Evidence base:

A at least one meta-analysis, systematic review of RCT or RCT rated as 1** (high quality) or a body of evidence consisting principally of studies rated as 1* (meta-analysis, systematic reviews or RCTs)

B a body of evidence including studies rated as 2** (high-quality systematic reviews or cohort studies)extrapolated from studies rated as 1** or 1*

C A body of evidence including studies rates as 2* (case control or cohort studies)or extrapolated from 2**studies

D Evidence level 3 or 4 (non analytical studies, case reports, case series and expert opinion)

1. Presentation

Headache on �15 days/ month that may be due to a range of underlying mechanisms and may be complicated by, or caused by, drug overdose (Goadsby 2006).

Consider prophylactic treatment if migraine >1 per month• Acute 1st line treatment: Topiramate• 2nd line treatment: PropranololNB Contraindications for asthma, COPD, peripheral vascular disease orunstable heart failure (P06)or consider amitriptyline (unlicensed indication)3rd line treatment: Acupuncture – NICE recommend 10 sessions of acupuncture over 5-8 weeks for those in whom both Topirimate and propranolol have proved unsuitable/ineffective.

2. History and examination

Diagnosis based on history and physical examination (optic fundi, BP, head and neck). SIGN give the following questions to consider when taking a history:

• How many different headache types does the patient experience? Separate histories are necessary for each. It is reasonable to concentrate on the most bothersome to the patient, but others should always attract some enquiry in case they are clinically important.

• Time questions:o why consulting now?o how recent in onset?o how frequent, and what temporal pattern (especially distinguishing between episodic

and daily or unremitting)o how long lasting?

• Character questions:o intensity of paino nature and quality of paino site and spread of paino associated symptoms

• Cause questions:o predisposing and trigger factorso aggravating and/or relieving factorso family history of similar headache

• Response questionso what does the patient do during the headache?o how much is activity (function) limited or prevented?o what medication has been used and in what manner?

• State of health between attackso completely well, or residual or persisting symptomso concerns/ anxieties, fears about recurrent attacks, and/ or their cause

Differentiating migraine from tension-type headache from Goadsby 2006

Characteristics Migraine Tension-type headache

Pain features of acute attacks

ThrobbingUnilateralWorsening of pain with movement

Boring or squashingBilateralNo effect of head movement

Associated features Nausea or vomitingPhotophobia and phonophobia

Triggering factors Altered sleep patterns (too much or too little) Skipping mealsOverexertionChange in stress level (too much or relaxation) Excess afferent stimuli (such as bright lights) Weather changeChemical (delayed headache after alcohol or glyceryl trinitrate)Menstruation

None

Psychological stress

Red flags from North Derbyshire guidelines

• Awoken by headache at night (not awakes with a headache)• Worst in the morning• Worsened by changes in posture, especially bending• Coughing, sneezing, straining or vomiting, exacerbates it• Associated with:

o vomiting & drowsinesso progressive neurological deficito cognitive changes

• papilloedema• meningeal irritation: look specifically for neck stiffness, back pain and Kernig’s sign• new neurological deficit

3. Migraine

Recurrent episodic moderate or severe headaches, unilateral and/or pulsating, lasting 4 to 72 hrs, associated with gastrointestinal (and sometimes visual symptoms).

Reassurance and identification/ avoidance of predisposing and trigger factors (e.g. stress, depression, menstruation, dietary, exercise)

4. Consider analgesic to manage pain

Opioids should be avoided. Triptans are not recommended as first line treatment. NSAIDs may cause GI irritation and occasional GI haemorrhage. Do not give if there is a history of peptic ulceration. NSAIDs may worsen asthma, hypertension, renal impairment or heart failure (Prodigy 2006).

• Acute 1st line treatment: simple analgesics (e.g. paracetamol orNSAIDS e.g. ibuprofen)

step up if unresponsive to

• 2nd line treatment: anti-migraine drugs (5HT-agonists)– NB can cause MOH (pathway 2)– or triptans

5. Consider anti-emetics to manage nausea and vomiting

• 1st line treatment: buccal prochlorperazine or metoclopramide

• Domperidone suppositories if vomiting is a problem.

Soluble preparations are preferred as they act more quickly. (P06)

6. Consider prophylaxis for acute prevention

Consider prophylactic treatment if migraine >1 per month

Consider prophylactic treatment if migraine >1 per month• Acute 1st line treatment: Topiramate• 2nd line treatment: PropranololNB Contraindications for asthma, COPD, peripheral vascular disease orunstable heart failure (P06)or consider amitriptyline (unlicensed indication)3rd line treatment: Acupuncture – NICE recommend 10 sessions

of acupuncture over 5-8 weeks for those in whom both. Topirimate and propranolol have proved unsuitable/ineffective

7. Consider referral for direct-access diagnostic CT to exclude secondary headache

If second-line treatments of acute symptoms fail or if diagnosis is uncertain, consider referral for neurological opinion and/or refer directly for head CT.

Consider prophylactic treatment if migraine >1 per month• Acute 1st line treatment: Topiramate• 2nd line treatment: PropranololNB Contraindications for asthma, COPD, peripheral vascular disease orunstable heart failure (P06)or consider amitriptyline (unlicensed indication)3rd line treatment: Acupuncture – NICE recommend 10 sessions of acupuncture over 5-8 weeks for those in whom both Topirimate and propranolol have proved unsuitable/ineffective.

8. Medication overuse headache (MOH)

Patients often use very large quantities of medication and pre-emptive use of medication, headache present on awakening in the morning and increases after physical exertion, diagnosis confirmed only when symptoms improve after medication is withdrawn.

9. Identify and stop analgesic causing MOH

Do not substitute another analgesic. Warn the patient that headache may become worse/ more severe for a period of days/ weeks before improvement and no analgesic must be taken in period.

10. If headache becomes intolerable

Opioid analgesics, including codeine are not recommended.

Replace causative analgesic with regular NSAID if necessary, unless actually NSAID

11. If patient is still having headache > 4 weeks reconsider investigation for migraine or chronic daily headache

Go to nodes 3 or 12

12. Chronic daily headache

Episodic, mostly lasting no more than several hours, or chronic, occurring on >15 days a month; can be unilateral but more often generalised, typically described as pressure or tightness, commonly spreads into or arises from the neck, lacks specific features associated with migraine.

13. Provide reassurance

Confirm not medication overuse headache, provide reassurance and identify contributory factors (e.g. stress, depression, musculoskeletal involvement).

14. Consider primary prevention as first measures

• Regular exercise is of general and potentially considerable benefit

• Physiotherapy may be appropriate for musculoskeletal symptoms

• Lifestyle changes, relaxation therapy, cognitive training, yoga and meditation to reduce stress

15. Consider medication as a second measure

Opioid analgesics, including codeine are not recommended.

• For episodic chronic headache, occurring on fewer than 2 days per week, aspirin, ibuprofen, paracetamol or NSAIDs.

• For frequently occurring episodic or chronic tension type headache – try simple analgesic first and step up to amitryptiline starting at a low dose with increments as side effects permit. Withdrawal may be attempted after improvement has been maintained for 4-6 months

Beware analgesic use > 2 days/ week for headache.

16. Consider referral for direct-access diagnostic CT to exclude secondary headache

If second-line treatments of acute symptoms fail or if diagnosis is uncertain, consider referral to secondary care for neurological opinion or direct access CT